Surgical device for the removal of tissue employing a vibrating beam with cold plasma sterilization

ABSTRACT

A surgical instrument for treating body tissues through narrow body passages employs an elongated cantilevered beam having a proximal end supported in a rigid block and a narrower distal end extendable through the narrow passages. One or more piezoelectric actuators are fixed to the beam surface and energized from an AC source through electrodes interspersed with the piezoelectric actuators to produce oscillatory motion of the beam distal end in multiple modes of movement with sensing electronics to monitor and control the distal mechanical movement. The oscillatory beam is assisted with cold plasma sterilization of the target tissue surface to be treated at the distal end.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application claims the benefit of priority to U.S. ProvisionalPatent Application Ser. No. 62/076,082, filed Nov. 6, 2014 and is acontinuation-in-part of U.S. patent application Ser. No. 14/641,791,filed Mar. 9, 2015. U.S. patent application Ser. No. 14/641,791 claimspriority to U.S. Provisional Application No. 61/950,924 filed Mar. 11,2014, and U.S. Provisional Application No. 62/039,783 filed Aug. 20,2014, the contents of which are incorporated herein by reference.

FIELD OF THE INVENTION

This invention relates to surgical instruments comprising vibratingbeams driven by macro fiber composites (MFCs) to dissect or remove ortreat body tissues through openings and passages to targets within amammalian body and assisted with cold plasma sterilization by applyingnon-thermal plasma to the treated area to destroy bacteria and biofilmscausing surface and invasive infections.

BACKGROUND OF THE INVENTION

Energy driven surgical tools which apply acoustic energy to tissues cancause tissue effects deep in the body structures through relativelylong, narrow passages. For deep and narrow surgery many devices andtechniques have been developed and used. For example, cold knifetechniques using knife blades or a rotating suction debrider such asmarketed by Medtronics have been employed. The latter is an improvementas it removes tissue and resulting blood. As procedures are usually donewith an endoscope any bleeding rapidly obscures any visualization of thesurgical site. To surgically manipulate tissue (disintegrate, incise,elevate and dissect) and not obscure the surgical field with blood,instruments which apply various forms of energy have been developed.These energies include heat, cold (cryosurgery), radio frequency, laserlight, plasma and sound. Each of these by itself has advantages andfaults. In this patent we present a device that purposely combines soundenergy with cold steel technique.

The earliest realization of sound's effects on solid structures datesback to the early 1900s when it was discovered that when a boatpropeller was rotated at a high speed the resulting cavitation coulddestroy the propeller. The effect was to cause or use small vaporbubbles within a liquid. A spinning propeller or sound energy as arepetitive production of powerful positive and negative movement in aliquid stores this energy in the walls of these vapor bubbles. The lifeof these high energy bubbles is very short and the stored energy isreleased quickly as the bubble collapses. In appropriate surgicalinstruments the energy of the bubble collapse is dissipated in fourdifferent forms: as a concussion wave that can break down tissue,through heat that is intense for a very short time and can causechemical reactions not otherwise possible, as micro streaming ofmovement on the bubble outer surface capable of cleaning a nearbysurface, and as a vortex that can drill into tissue cells, known assonoporation.

Ultrasonic devices on the market today produce enough energy to cause acontrolled tissue disintegration. The ultrasound is created proximally,concentrated into a waveguide, and conducted to a distal tip wherecavitation is created. As the cavitation is the only working energy inthis tool, very large ultrasonic generators are needed. Usually this isdone with stacks of piezoelectric ceramic discs or a magnetostrictivesystem. A typical piezo actuator is constructed as described byLangevin. A stack of piezo ceramic discs are squeezed tightly between ablocking mass and a condenser using a bolt. As sound energy is createdit travels in both a proximal and distal direction. The blocking massprevents the spread proximally. The energy is thus all concentrated intothe condenser which narrows on its distal end. A waveguide is attachedto the condenser to then carry the sonic energy to the target. As theobjective is to cause resonance in the waveguide trying to condense theenergy at an antinode the length of the waveguide is dependent on thefrequency of the sound. To achieve high energy levels at the distal enda thick, straight and rigid waveguide is created. The material transmitssound at a relatively high speed (for example using a titanium alloywith speeds of about 6100 m/s). The goal is to achieve resonance of thewaveguide and produce an antinode at the distal tip. To do this a largeamount of electrical energy is required. Once the tip of the resonatingwaveguide is placed in contact with tissues, the sound energy enters thewater based tissue and creates cavitation. The cavitation destroys orotherwise is used for surgical purposes.

The cavitation occurs as a spherical cloud around the tip of theinstrument. A smaller instrument has a smaller cloud and is thus bothmore precise and restricted in the speed of action. Such a device isused for cataract surgery, a very precise surgery.

The CUSA (cavitron ultrasonic surgical aspirator) is used in brainsurgery. A larger energy source and waveguide associated with a suctiontube is used for neurosurgical removal of brain tumors. Its advantage isthe destructive cavitational effect on high water content tissue likebrain tumors with little effect on relatively drier tissue like normalbrain tissue, collagen and blood vessel walls. The cavitation produceddisintegrates the tumor and an integrated suction removes the detritus.The difference in water content results in surgical precision at lowerpowers.

Another surgical tool that uses ultrasound is a harmonic scalpel. Arapid longitudinal, reciprocating movement imparted into a scalpelshaped blade results in cutting of tissue. The associated heat generatedcauses coagulation. The cutting is very precise due to the high rate ofmovement and the narrow loss of cells in the kerf.

Other surgical instruments employ tissue welding and coagulationproduced by sound energy reduced to heat as a waveguide transmits sonicenergy to tissues. Blood vessels can be fused closed or various clipscan be fused to clamp vessels.

In the early 1990s trials of the CUSA for intranasal surgery(polypectomy) were conducted. This tool was excellent at removing tissuealmost bloodlessly but was exceedingly slow. Trial use of CUSA fortonsillectomy has also been published. The advantages were preciseextracapsular excisions with little bleeding.

The SonoPet was introduced recently for otolaryngology work. It is alsoa rigid straight hollow waveguide that suctions blood and detritus. Italso is marketed with a variety of rasp tips for vibratory motion andbone abrading. From a nasal surgery standpoint, it is very good forabrading through bone into the frontal sinus and between the nose andbraincase, with its greatest advantage being the slow precision indangerous areas.

A device developed in Russia and found in eastern European clinicscalled a Tonsillor is another high-energy ultrasonic device. It is verypowerful as it too works primarily through cavitation. It is proximatelybulky and has a long, relatively thick, rigid waveguide with a varietyof tips. It is used near the external surface and straight into thenasal passage as it is too large for precise intranasal work deep in thenose.

Other devices have been proposed that add ultrasound to a rotatingsuction knife device (debrider, Hummer, and the like).

Separately, cold plasma technique is used not only to staunch any bloodflow from the treated area to prevent the bleeding from obscuring thevisualization of the surgical site, the cold plasma is also used tosterilize the treated area.

Take the treatment of sinusitis for an example. Although today'ssophisticated minimally invasive surgery combined with washing atsurgery with topical antibiotics at high concentration andcorticosteroids is effective at treating acute sinusitis, recurrentinfections often occur and treatment of chronic sinusitis is not aseffective.

Although there is no proof that a biofilm is the cause of chronicsinusitis, it has been shown that biofilms are present on the mucosalsurfaces in the paranasal sinuses involved in chronic infection.Biofilms are microbial communities attached to a surface and embedded ina matrix composed of exopolysaccharides together with proteins andexcreted nucleic acids. Biofilms are composed of many different speciesof bacteria, yeasts, and fungi. It is known that many types of bacterialbiofilms are less susceptible to antibiotics due to the dense andprotected matrix of the film as the outer layer of cells protects theinterior of the community. Intuitively, the treatment targeted atbacterial biofilms on the mucosal surfaces using treatment other thanantibiotics is called for.

Several studies have shown that an approach to inactivate bacterialbiofilms is by means of non thermal plasmas. Plasma results from theenergy transfer from a source, usually an electric discharge, to thesurrounding gas. A part of gas molecules is raised from their energyground state to an excited one with a modified electron distribution.The most commonly used method of generating plasmas is by applying anelectric field to a neutral gas, such as helium or argon. Thenon-ionized gas remains at or near ambient temperature if the energy ofvery small electrons is higher than the one of larger mass radicals sothe plasma is considered “cold” or “non thermal.” One of the advantagesof using cold plasma sterilization in biomedical applications is theatmospheric conditions of the cold plasma without the need of a vacuumsystem. Furthermore, plasma sterilization is considered safe both forthe surgeons and the patients as the amount of current carried isminiscule and has no electrical effect since plasma is quasineutral. Inaddition, the radicals produced, termed reactive oxygen species (ROS),which are creations of oxygen and nitrogen and water in air or othersurrounding environment, have chemical interactions with bacteria andtissue and result in plasma being a very effective sterilization method.

SUMMARY OF THE INVENTION

It is the purpose of the present invention to provide surgicalinstruments employing vibrational energy of an elongated beam combinedwith cold plasma technique to treat diseases through narrow passagessuch as the nasal passages and associated paranasal sinuses. For thepurposes of this patent we will often cite surgery of the nose andparanasal sinuses. Those familiar with the art will understand that thisdevice and method of surgical technique can be applied elsewhere. Thisdevice uses a narrow beam as a waveguide that is thin, at times curvedwith a small proximal end energy transducer. It works using bothultrasound and vibratory action so that it provides the advantages ofcavitation plus tissue destruction with hemostasis of small vessels butcan also provide a whipping/vibratory action at the beam tip. It isself-correcting for tissue effects on the beam and also can monitor thetissue viscosity for the surgeon to alert encountering bone or passingthrough tissue into air-containing spaces. This is all made possible bysmall flat transducers (macro fiber composite pads (MFCs)) andelectronics that allow a mixing of ultrasound and acoustic vibration todo work at the distal end. The electrical source is direct currentbattery power.

The devices of the present invention for surgical tissue resection arequite different from previous ultrasound tools.

First, the thick, rigid, rod-like waveguides of modern ultrasound toolsare substituted with a flat beam of stainless steel or some other rigidmaterial. Second, the ultrasonic energy transducer is a Macro FiberComposite (MFC). An MFC is a piezoelectric device which consists oflayers of electrical insulator, interdigitated positive and negativeelectrodes, piezoelectric ceramic fiber, interdigitated positive andnegative electrodes, and electrical insulator in that order, bondedtogether with a polymer or resin matrix into a patch form-factor. Anelectric field applied by the embedded electrodes poles (aligns on amolecular level) the crystals of the piezoelectric ceramic fibers toeffect a mechanical elongation or contraction of the fibers. One or moreMFCs are bonded to a widened proximal end of the aforementioned flatbeam and conduct their mechanical energy down the length of the beamtoward a tapered distal end as sonic and ultrasonic waves. To provideadequate mechanical force to distort the flat beam, multiple MFCs may bealigned or layered upon one another and electrically actuated in unison.Thirdly, the flat beam is cantilevered from a relatively massiveblocking mass made of a highly rigid and dense material. This blockingmass serves to reflect stray sonic and ultrasonic waves toward thedistal end of the flat beam. Fourthly, by controlling the phase ofactuation of MFCs on either side of the flat beam, two modes of motionmay be generated. An extensional motion (Fz mode) may be generated byactuating MFCs on either side of the flat beam in unison (0 degree phaseshift). This Fz mode is characterized by a high-frequency, lowdisplacement motion of the distal tip capable of inducing fluidiccavitation of animal tissues in contact with the distal tip of the beam.Alternatively, a transverse motion (My mode) may be generated byactuating MFCs on either side of the flat beam in an opposing fashion(180 degree phase shift). This My mode is characterized by alow-frequency, large-displacement whipping motion of the distal tipcapable of minute tearing of animal tissue. Rapid transition between theFz and My modes results in excellent tissue destruction and localhemostasis at the distal tip of the flat beam with precision control.

The output of the generator is wired to the MFCs and controlled by anH-bridge circuit that allows for very rapid switching between modes ofMFC energization where MFC movement is mutually reinforcing, causingaxial movement and at other times causing a bending movement of the beamtip. The result is movement of the tip in two planes to do the work oftissue removal. The MFCs can respond to rapid changes in excitation andthis device makes use of two motions in the beam—a movement along thelongitudinal axis of the beam (the Fz mode) and a movement in which theMFC on one side of the beam is expanding while the MFC on the other sideis contracting (the My mode)—to cause the beam tip to move transverse tothe beam plane. The My mode motion can be adjusted to a high frequencywhich essentially causes tearing and/or churning of the tissue, and theFz motion can be turned on and off so rapidly as to appear simultaneousand thus cause tissue destruction by both tearing and cavitation. Thecavitation also aids in initiating coagulation. The most deflection inthe My mode is at the resonate frequency, however harmonics of the Myresonate frequency will also cause significant distal end movement.

The duration for each mode and any delay between switching of modes isentirely controllable. This rapid interplay of these two movementsresults in excellent tissue destruction under precise control.

As the device uses both an Fz and My movement, the need for a relativelythick and rigid waveguide is obviated. This allows freedom to use anynumber of designs. The simplest beam cross section is a rectangular flatbeam. The beam material may include stainless steel, titanium, aluminum,layered graphene, and even Pyrex or industrial diamonds. The choice isbased on the efficiency of transmitting sound energy, the speed of soundthrough the beam material, the stiffness of the material, and the needto bend the beam for specific anatomic access.

The efficiency of transmission is important so as not to lose soundenergy as the sound travels from proximal end to distal effector end.Certain crystalline structures tend to dissipate the sound or redirectit. Stainless steel and titanium are excellent for transmission.

High-speed transmission of the sound energy within the waveguide resultsin a high angle of internal reflection as the sound moves through thematerial. This is important for the situation calling for a bend in thecantilevered beam such as for ergonomic purposes and for placing thedistal tip in an optimal position relative to the surgical site. If theangle of internal reflection is too small, the energy will prematurelyexit the beam.

The shape of the beam is wide at the proximal end to accommodate theMFCs and the blocking mass. The beam then rapidly tapers toward thedistal end or tip. The more the beam narrows, the higher the energyconcentration at the tip. The shape of the taper varies. In a preferredembodiment the curve is a Bezier. Other curves have advantages as wellincluding a catenary and an exponential or a logarithmic curve. Straighttapers and stepped beams are not as efficient. The distal tip can bethinned between the two flat sides near the tip. The thickness of thebeam is based on the stiffness of the beam material and the amount ofwhipping action desired. If the beam is too thin, the whipping is slowand weak. Too stiff and it only produces limited movement.

Other cross-sectional beam shapes are possible. A circular shape or rodwill have less bias on tip movement. This, in combination with Fz and Mymovement, can trace many paths that can be used for more rapid tissuedestruction. Ribs on the side of a rod beam can direct the movement.Also the combination of Fz and My movement will increase the area of thetissue destruction reducing the time it takes to do the surgery.

The distal tip can be one of many shapes. For movement in the Fz mode(along the longitudinal axis of the beam), the larger the area of thebeam's end, the more negative pressure imparted to the liquid and thebetter quality of cavitation. A flared flat end presents more area tothe target tissue. If a flat end is tilted it will enter tissue better.The more surface area in the tissue, the more tissue that issimultaneously removed. Thus, inserting the flared flat end into thetissue produces cavitation on both of its sides. Another embodimentwould have a series of these tilted flat surfaces with a sharp tip,essentially creating a screw shape for easy insertion into the tissueand thus causing a long region of tissue disintegration.

As the flat beam has a transverse (My) movement in one direction only, atwist in the beam end can turn the tip 90 degrees and present the tipmovement along a different axis. If this edge is sharpened it becomes aknife-edge and makes this My movement applicable to incising. Othershapes are useful. A saw tooth can be used to cut bone, a rasp canabrade bone, and other tips are useful for dissecting through tissue,causing subsurface disintegration, elevating tissue off of bone, andcausing coagulation. Those familiar with the art can devise othershapes.

The actual surface of the beam tip is important to ways of increasingefficiency of the tissue effect. Thus, a claw end or a file end can beused for tearing tissue and for wearing down bone. This is moreimportant in the My movements.

Where cavitation is important a space between parts of the tip producesincreased effect. A simple example is the open slotted end. This can bemodified as a closed slot or a circular or hoop shape.

The MFC can be made as a cylinder with a spiral piezo composite. Thiswill produce a twisting action in the beam. Placed on the proximal endof a cantilevered rod the tip movement can attain an M_(y) mode that ischaotic. Specially designed outer ribs on the rod or conversely slotsalong the rod can create various patterns of movement.

More advanced beams use multiples of these basic, simple flat beams orcan be of a hollow rod shape. Using the walls of a hollow rod or tubularshape is very efficient in carrying sound energy. The end of a tube beamcan have multiple slots and thus produce a series of tabs or fingersthat act each in its own My plane causing very effective tissuereduction. The effect is to increase the amount of energy brought to thetarget tissue. More energy results in faster tissue removal. Also, thesearrangements can house suction and irrigation ports as well as a portfor an endoscope within the tube, an advantage in freeing a hand of thesurgeon.

Of importance is the blocking mass at the proximal end of the beam. Thisis both the clamp for the cantilever and for preventing sound energyfrom traveling proximately toward the surgeon. The block is made of highelastic modulus material (for example steel or tungsten) and as suchdoes not absorb much energy and actually reflects it back in a distaldirection. The blocking mass has a very high density and reflects thesound waves efficiently. The distance between the blocking mass and theMFCs is critical to efficient transfer of as much energy possible in adistal direction. The ideal distance is such that the waves reflectedoff of the blocking mass are in phase with the waves from the MFCs goingtowards the distal end of the beam and do not destructively interfere.

One advantage of the MFCs is their rapid response to changes in currentflow with relatively large elongation and contraction. In addition, thelack of hysteresis results in high response rates up to about 100 kHz.

Another advantage is the flat configuration and the ductility of the MFCpad. This makes design of the beam easier while still preserving theability to visualize the target tissue deep in a passage and yet have anergonomically comfortable tool.

The MFCs are preferably attached to the beam with high shear strengthepoxies that can withstand the large forces at play. The relation of thepads relative to each other are in a lengthwise or in a lateralorientation. Thus, MFC pads can be applied to the beam side to side witheach other or end to end along the longitudinal axis. The proximal endcan be lengthened or widened to accommodate more MFCs. A widened flatbeam can be bent for ergonomic reasons and still have high energy levelsdelivered. MFCs can be cemented on opposing surfaces and interact withother additional MFCs. MFCs can be stacked on each other, though from apractical standpoint a stack of three is the maximum used. The firststacked MFC adds only another 50% of the power of the MFC attached tothe beam and the second stacked MFC only adds an extra 25%. Using thesemanipulations, a large number of MFCs can be activated in unison for thedelivery of a powerful end force.

The simultaneous stimulation of all the MFCs in synchronism will producesubstantial longitudinal (axial) reciprocation and power. This is neededfor cavitation. In contradistinction, if the MFCs are made to actuate ina temporally staggered manner across the beam with the signals to theMFCs on one side producing elongation when the fibers on the opposedside produce contraction, the result is a transverse wave and asubsequent whipping action. This transverse wave may produce a standingwave that approximates the natural frequency of the beam waveguide.

MFCs can also act as sensors. A tiny MFC attached to the beam cangenerate signals that vary with the distal end motion. As the beamencounters different tissues with differing viscosities or stiffness,the amplitude of the signals change. This is sensed through a feedbackcircuit and the frequency in the beam can be adjusted. At the same time,the changes in amplitude can be used to alert the surgeon. The currentdrawn by the device can also be used to monitor resistance and dampeningby the beam due to different densities of the material. In an examplesituation, with a rapid dampening or a change in the stiffness orviscosity of the tissue may indicate that the beam is nearing bonyattachment. Sudden increase in amplitude indicates the beam has exitedthe tissue and is sitting in air. Detection of either of these events isof importance to the safety of surgery.

Key to this invention is the ability to intermingle two movements at thedistal end of the beam. These two movements are produced by theinteraction of the MFCs on the proximal end. In its simplest form an MFCis applied on either side of the proximal portion of the flat beam. Ifthe electrical potential is applied at the exact same time to each andthey are poled to move in the same direction, an extensional mechanicalor sound wave is sent down the beam. This is the Fz movement. If,however, the stimulation of the two sides are out of phase by 180degrees, one MFC will be lengthening and the other will be contracting.This will cause a bending of the beam at the midpoint of the two MFCsand is equivalent of a transverse force applied at right angles to theflat side of the beam. This is the My movement.

To make this rapid change the electronic control of the electrical poweris key. In one preferred embodiment an H-bridge is used to rapidlyswitch the excitement of the two MFCs. In this preferred embodiment theelectrical signal can be turned on and off very rapidly. Thus, veryshort bursts of high frequency waveforms to create Fz and then lowfrequency waveforms to create My movement can be intermingled. Thebursts and intervals are so short that it appears as if both areoperating at all times. Yet the activity of each is different. Fz isproducing the kind of motion that produces cavitation for tissuedestruction by cavitation as well as exciting local coagulation. The Myis producing a much slower movement that whips the tip to tear or incisethe tissue. The result is disintegration of the tissue or cleanincisions depending on the tip used. For different purposes the amountof time in each mode can be varied. Overall there is disintegration orincision or dissection or coagulation or other treatment effects createdat the distal end of the beam.

In the brief intervals between these two modes a fast sensor can lookfor dampening of the tip motion. A feedback to the microprocessor whichcontrols the signal generator can compensate for the dampening. Againthe feedback is continuous so seamless monitoring and control isachieved.

The electrical power for this device in one preferred embodiment is a DCcurrent provided by a battery, however a medical grade isolationtransformer and power supply will also work. This current is controlledby a MOSFET to produce a square wave signal in the primary of atransformer. The voltage is stepped up in the secondary to hundreds ofvolts. The square wave leaving the secondary passes through a capacitorand a diode forming a clamping circuit. A sine or triangular wave isformed and drives the MFC such that they are forward biased in the Fzmode. This is important as the MFCs typically can be driven to +1,500volts in the forward biased mode, but only 500 volts in the reversedbiased mode. Important for this device is the low voltage (battery)source for the transformer. Besides making the device more transportableit is safer than a conventional wall source and obviates concerns of aground fault and possible electrocution of the patient or surgeon.

In a preferred embodiment of the present invention, non-thermal (cold)plasma is supplied to the surfaces of the target tissues within the bodycavities. The cold plasma generator along with the elongated beam of thepresent invention form an integrated surgical instrument similar to aconventional endoscope.

The plasma may be generated by applying an RF alternating current or apulsed direct current to a flow of any useful gas, or gas mixture, suchas air noble gas plus oxygen. This may be done near the proximal end ofthe probe by applying the electrical power to spaced electrodes in thegas flow and allowing the gas flow to carry the resulting plasma to thedistal end of the probe near the target tissues, or by generating theplasma at the distal end either by the application of current or voltagebetween spaced electrodes or through a known technique of dielectricbarrier discharge (DBD).

The cold plasma generator in one preferred embodiment includes a plasmaelectrode extending along the length of the beam terminating at a secondplasma electrode located at the distal end of the beam. A gas supplytube extending along the length of the beam carries a gas such asoxygen, nitrogen, air or water vapor which is expelled at the distal endof the tube against the second plasma electrode. The electric fieldestablished between two plasma electrodes breaks down and ionize the gasand creates plasma.

In an alternative embodiment, the plasma is generated at the proximalend of the endoscope. In this case, the plasma generator takes the formof an attachment to the endoscope. The present invention contemplatesinsertable plasma applicators that can be added to any therapeuticendoscopic device. Inserts formed in accordance with the presentinvention may generate a plasma at the proximal end that is carried bythe pressure of flowing gas out the distal end. When the plasma insertis used, the flow channel is preferably nonconductive to preventdissipation of the plasma, and if the endoscope channel is formed ofconductive material, a nonconductive tube is required as part of theinsert.

The device of the present invention may include channels for irrigationflow, suction and therapeutic agent delivery. It also includes opticalfibers for illumination of the target tissues and for imaging of thetarget site from the proximal end through a viewing window.

In order to spread the application of a plasma over the target tissuesto be treated, another embodiment utilizes a double balloon diffusersupported at the distal end, the inner balloon sitting within the outerballoon, and the inner balloon having a conductive coating, such asMylar on its inner surface, connected to a plasma electrode. Shortfibrous webs or plastic foam may be used to connect the inner surface ofthe outer balloon and the outer surface of the inner balloon andmaintain a spacing between the two. The inner balloon is connected tothe gas supply. The volume between the inner balloon and the outerballoon is filled with pressurized gas through the apertures on thesurface of the inner balloon. The outer balloon has multiple tiny holesand may take the form of mesh. When an electrical power is appliedbetween two plasma electrodes, the gas will be ionized and the resultingplasma will fill the volume between the balloons and extend through themesh as multiple plumes which treat the tissue surface.

BRIEF DESCRIPTION OF THE DRAWINGS

Other objectives, advantages, and applications of the present inventionwill be made in the following detailed description of preferredembodiments of the invention. The description makes reference to theaccompanying drawings in which:

FIG. 1A is a plan view of a cantilevered beam used in a preferredembodiment of the invention and having a slotted tip;

FIG. 1B illustrates the cantilevered beam of FIG. 1A with macro fibercomposites (MFCs) adhered to one of its surfaces, with two MFCsconnected in parallel;

FIG. 1C is a side view of the cantilevered beam of FIG. 1B;

FIG. 1D is a side view of a cantilevered beam, like FIG. 1C, with itsdistal end embedded in a sound blocking clamp;

FIG. 2 is an enlarged side view of the section of the cantilevered beamhaving MFCs applied to its two opposed surfaces;

FIG. 3A is a perspective view of the cantilevered beam of FIGS. 1A-1D,having a straight distal end;

FIG. 3B is a perspective view of a cantilevered beam having a downwardlycurved distal end;

FIG. 3C is a view of a cantilevered beam having a straight distal endwith a proximal end widened to accommodate additional MFCs;

FIG. 3D is a perspective view of a triangular beam supporting multipleMFCs at its proximal end and having a channel that can carry suction,irrigation, and other devices to augment tissue ultrasound interactions;

FIG. 4 is a side view of a cantilevered beam employing two parallel beamsections at its distal end and having MFCs adhered to both outer sidesof the two beams and having its proximal end anchored in a relativelymassive sound blocking clamp;

FIG. 5A is a plan, partially broken away, view of a tubular cantileveredbeam;

FIG. 5B is a cross section taken along line A-A of FIG. 5A;

FIG. 5C is a cross section taken along line B-B of FIG. 5A;

FIG. 5D is a cross section taken along line C-C of FIG. 5A;

FIG. 5E is a cross section taken along line D-D of FIG. 5A;

FIG. 6 is a detail of the distal end of a hollow beam tip with slottedends;

FIG. 7A-7H and 7J-7T illustrate a range of cantilevered beams havingdifferent tips for use in various surgical situations;

FIG. 8 is a perspective view of the distal end of a cantilevered beamfor use with the present invention having a 90 degree twist at itsdistal end to convert an My movement into a cutting movement;

FIG. 9 is a block diagram of a computer controlled system for generatingAC driving waves for the MFCs employed with the present invention andfor detecting the beam's tip displacement for feedback purposes tocontrol the generated signals; and

FIG. 10 is a diagram of a preferred version of the MFCs.

FIG. 11 is a perspective view of a triangular beam supporting multipleMFCs combined with a cold plasma generator and an exploded perspectiveview of components of a cold plasma generator;

FIG. 12 is an illustration of a conformal balloon used to expand intothe contours of the body cavity and generate plasma for therapeuticapplication.

FIG. 13 is a perspective view of a therapeutic endoscope with multiplechannels showing an insertable cold plasma applicator.

DETAILED DESCRIPTION OF PREFERRED EMBODIMENTS OF THE PRESENT INVENTION

The present invention broadly employs a cantilevered beam, relativelyrigidly supported at the proximal end and free to oscillate at thedistal end, supporting MFCs on its surface which are electricallypowered to induce a variety of motions of the distal end of the beam. Afirst preferred embodiment of the beam is illustrated in FIGS. 1A-1D.

The beam itself, indicated at 10 in FIGS. 1A-1D, is formed as a thin,generally flat beam formed of a sheet material, preferably stainlesssteel, but which could include other materials, in particular metals,which are relatively rigid such as titanium, aluminum, or materials suchas graphene, Pyrex glass, or industrial diamonds. The beam 10 preferablyhas a relatively uniform thickness along its length, which may be in therange of 0.0040 to 0.0070 inch.

The relatively wide end of the beam, referred to as the proximal end 12,is relatively rigidly supported in a blocking mass generally indicatedat 14 in FIG. 1D and consisting of a pair of metal blocks 16 which havemating flat surfaces that clamp the proximal end 12 of the beam 10. Theclamp may be formed of a dense metal, such as tungsten, to betterreflect proximal directed vibrations from the MFCs. The free end of thebeam extending beyond the clamp 14 may typically be 7 inches in lengthor multiples of the half wave length, all dependent on the frequencyused. The proximal end 12 of the beam 10 may have a width in the rangeof 0.4 to 1 inch in width while the distal end 18 of the beam maytypically have a width of 0.8 inch. Other dimensions are possible. Therelatively wide proximal end of the beam 12 and the distal end of thebeam 18 are connected by a curved and tapered section 20. As has beennoted, the preferred embodiment of the taper is a Bezier curve. Othercurves such as a catenary, an exponential, or a logarithmic curve may beemployed as well as a straight taper and a stepped beam. The beam may bethinned toward the distal end 18.

The MFCs are typically flat and rectangular, and as illustrated in FIGS.1B-1D may be applied to both flat sides of the beam 10 at a slightlyseparated distance from the blocking mass 16. As disclosed in FIG. 10,subsequently described in detail, each MFC consists of rectangular rowsof piezo crystals embedded in a fibrous composite and shaped into rods.These are sandwiched between layers of adhesive, electrodes, and aprotective film. The electrodes are attached to the film in aninterdigitated pattern which transfers the applied voltage directly toand from the ribbon-shaped rods. The MFCs are available from SmartMaterial Company, Sarasota, Fla., and are described in U.S. Pat. No.6,629,341, the disclosure of which is incorporated herein by reference.These MFCs may be applied to structures so as to bend or distort thestructures, counteract vibrations, or generate vibrations. The materialsalso act as a very sensitive strain gauge, sensing deformations, noise,and vibration, making them useful for the feedback applications of thepresent invention.

In order to control the MFCs, a microcomputer will be used. It may be anembedded computer or an external computer.

The computer will control the frequency, amplitude and phase of the MFCsand may have a user interface that can contain buttons, potentiometers,and a display (not shown). This computer will also have sensor inputs tomonitor the beam while in use. One sensor can be a section of an MFCepoxied on the beam that will generate a voltage proportional to thebeam's vibrations. Yet another sensor will be a current sense of thegenerator power. In practice, the current draw will increase when thebeam distal end encounters material such as tissue and bone. The currentdraw is minimum when the beam is subjected to air.

The MFC or other piezo sensor voltage will be maximum at the beamresonance frequency, and will decrease when the beam is pulled offresonance by encountering tissue or bone. Normally the microcomputercode will change frequency to obtain resonance again, however if itdetermines that bone has been touched, then it will shut down thegenerator and alert the surgeon. There may be cases where bone must bedestroyed as well, and this would be a user input to the computer sothat it would not shut down the generator, and would optimize thefrequency, amplitude, and phasing of the MFCs to achieve the desiredresult.

The embedded microcomputer can be connected to a PC or other computersuch as a tablet. This will provide for data recording, graphing, andsending new code to the embedded microcomputer so that it will beoptimized for the particular operation.

Time stamping of the data will occur at the embedded micro and will besent along with the data.

Additionally, an endoscope camera (not shown) can be connected to the PCor other computer so that the data from the embedded micro can be timesynchronized with the camera data for post processing, statisticalanalysis, and teaching other doctors, medical students and others in themedical field.

The connection from the embedded micro to the line powered PC will bedone so that no common grounds are shared. This is used to preventground faults from the line power computer to be transferred to thepatient or surgeon. This can be accomplished by wireless transmission,or an optically isolated link such as an OPTO USB connection.

In FIGS. 1B and 1C two layers of MFCs are applied to each side of thebeam 10. MFCs 22 a and 22 b are applied to the top side, with the unitslargely overlapping and only the underside units' electrical contactsbeing exposed. As shown in FIG. 1B, these contacts are preferablyconnected in parallel by wires 24 and 26. The two bottom layers 22 c and22 d are similarly disposed and configured and may be connected inparallel to the upper units 22 a and 22 b to provide largerdeformations.

The beam 10 has a slot 28 at its distal tip for purposes of enablingvarious surgical operations. A variety of other tip designs, some ofwhich are illustrated in FIG. 7, may be employed.

FIG. 2 is an enlarged side view of the section of the beam 10incorporating the MFCs. FIG. 2 illustrates the electrical contacts 30 aand 30 b for the two upper MFCs and 32 c and 32 d for the lower MFCs.The MFCs are powered by battery powered AC generators illustrated inFIG. 9.

FIGS. 3A, 3B, 3C, and 3D are perspective views of various beamconfigurations for the cantilevered beams of the present inventionshowing their supported MFCs 22, but not the blocking masses 14. FIG. 3Aillustrates a straight beam, much like illustrated in FIGS. 1A-1D; FIG.3B illustrates a beam curved along its length; FIG. 3C illustrates abeam having panels which extend normally to the MFC units 22 to supportadditional MFCs 34 a and 34 b on one side and 34 c on the opposed side.FIG. 3D illustrates a beam having three sections, 36 a, 36 b, and 36 cjoined together at their edges in a triangular configuration enclosing acentral space that can carry various ports (not shown) for purposes likesuction, irrigation, endoscopy, and other surgical purposes. The outersides of the sections 36 a and 36 b can carry MFC units 38, which canintensify the motions induced by the MFCs 22.

The dual layer beam 40, 42 illustrated in FIG. 4 has two overlying MFCs44 and 46 on one of its outer sides and MFCs 48 and 50 on the otherouter side. The proximal ends of the beams 40 and 42 are supported in arelatively massive sound blocking clamp 52 comprising a pair of elements54 and 56 each having flat, mating surfaces. The proximal ends of thetwo beams 40 and 42 are embedded in an opening in the blocks 54 and 56and separated by a spacer 58. The blocks 54 and 56 are adapted toaccommodate screws (not shown) which pass through the block 54 andthread in the block 56.

This configuration can provide strong energy delivery to the distal endsof the beams 40 and 42. The distance from the MFCs to the clamp 52 ispreferably an integral number of wavelengths to ensure that thevibrations passing in the proximal direction from the MFCs will bereflected by the clamp, back to the MFCs, so that they reinforce, ratherthan cancel, the basic vibrations made by the MFCs.

FIG. 5A discloses an embodiment of the invention employing a tubularcantilevered beam generally indicated at 60. This embodiment has theability to accommodate a plurality of MFCs 62 which are illustrated inthe cross section of FIG. 5D. A total of eight MFCs are employed withfour of them, denoted 64, being spaced about the outer side of the beamand an additional four, denoted 66, are accommodated on the interior ofthe beam. These can be stacked with a theoretical 24 MFCs acting on thebeam. This provides a high energy output at the distal end of the beam60. The interior of the beam can accommodate one or more ports 68 whichcan carry irrigating fluid and provide suction removal for the destroyedtissue and any irrigating fluid. It could also carry a rigid or flexiblefiber optic endoscope for surgical viewing. The tube 60 may graduallyconverge into a square shape 68 in a proximal direction, so that theproximal end 70, illustrated in cross section in FIG. 5E, is fullyrectangular. This rectangular proximal end can accommodate a number ofblocking masses 72 on its four sides which increase the overall mass ofthe proximal end of the tube. Screws 74 join the masses to the proximalend.

The separation of the MFCs 64 from the blocking mass 72 is designated 19in FIG. 5A.

In another variation of the invention a tubular beam tip, illustrated inFIG. 6 as 80, may have a number of slots 82 creating “fingers” extendingfrom its distal end to allow for increased whipping action of the distalend and transfer of energy into the tissue to be treated.

The distal tips of the beam may take any of a variety of forms useful tothe surgeon to perform particular operations. FIGS. 7A-7H and 7J-7Tdisclose a variety of tip forms. FIG. 7A shows the distal end of acantilevered beam 90 having a flat, plain end.

FIG. 7B illustrates a beam end having a flat end expanded laterally at84 to form a circular end.

FIG. 7C shows a similar flat end 86 which is angled with respect to thecentral axis of the distal end of the beam. This allows easier entryinto tissue so the entire flat plane can be inserted.

FIG. 7D shows a distal end taking the form of a screw 88. Multiple flatplates as in 7C are arranged on the distal end of the rod beam with asharp screw point to start the end piece into the tissue. Thus allplates may generate cavitation and movement.

FIG. 7E is a distal end with a flat end extended laterally and a concaveflare 92 at the immediate distal end adjacent to the end 90.

FIG. 7F shows a plain flat rectangular distal end for the beam.

FIG. 7G illustrates a beam end with a slot parallel to the axis of thebeam immediately adjacent the end of the beam, with the slot closed offby the beam.

FIG. 7H is an illustration of a beam end with an open slot 98. The widthof the slot can vary as well as the shape of the sides of the slot

FIG. 7J is an illustration of a beam end with a rounded edge 100. Thiscan also be a sharp edge.

FIG. 7K is a perspective view of a beam end with a looped slot 102.

FIG. 7L shows a beam with a distal end 104 which is decreased inthickness relative to the proximal balance of the beam.

FIG. 7M is a plan view of a beam end with a dissector tip 106.

FIG. 7N is a side view of the tip 106.

FIG. 7O is a plan view of a beam with a disintegrator tip 108.

FIG. 7P is an end view of the tip 108.

FIG. 7Q is a plan view of a distal tip end 110 which is elevated out ofthe plane of the balance of the beam as illustrated in FIG. 7R. This tipis useful for elevating soft tissue off of a bony surface.

FIG. 7S is a plan view of a beam with a coagulation tip 112 which has atapered pointed end 114 as illustrated in FIG. 7T.

FIG. 8 illustrates a distal end for a beam 116 with the distal end 118twisted by 90 degrees out of the plane of the proximal portion of thebeam and ending with a sharpened cutting end 120 for cutting softtissue. This could alternatively be a saw-tooth type end or the like forproviding bone cutting motion based on actuation of the MFCs to produceMy movement. This end could also end as a rasp for thinning or removingthin layers of bone.

The control signal generator and feedback circuit for the beam 10 isillustrated in the block diagram of FIG. 9. Broadly, the circuitoperates upon a DC supply to generate an alternating current signalapproximating a sinewave or triangular wave or saw-tooth wave to powertwo MFCs disposed on opposite sides of a cantilevered beam, designatedthe top MFC 910 and the bottom MFC 912 disposed in a beam 911, asillustrated in FIG. 9. The circuit also uses an MFC as a signalgenerator 913 to detect the deflection of the tip of the beam 911 andfeed that signal back through a peak detector 916 to the circuit whichgenerates the AC signal for the two MFCs.

The power for this device is a battery 902 or some other source of DCpower that can produce a DC voltage for operation on by microcomputer904. The microcomputer 904 employs an analog to digital converter 901which generates a DC voltage control signal on line 900. The signal isprovided to a DC to DC power supply 903. The voltage from this powersupply is then applied to the primary 918 of a step-up transformerforming part of what is termed a “sinewave generator” although thesignal may be more like a triangular wave or saw-tooth wave. Thesinewave generator is composed of the microcomputer 904; the battery902; the DC to DC power supply 903; the step-up transformer 918, 907; anegative clamp 908; a MOSFET driver 905; a MOSFET 906; and an H-bridge909.

With the beam tip exposed to free air, the microcomputer programmingwill maximize the output of a voltage sensor 913 which measures thedisplacement of the tip of the beam 911. The sensor 913 can be formed byan MFC which produces a voltage when movement is encountered. Thepositive peak detector 916 produces an AC voltage that corresponds tothe peaks of the tip motion sensed by the voltage sensor 913 andproduces a voltage proportional to the displacement of the beam tip.Under control of the signal from the peak detector 916, themicrocomputer 904 produces a square wave that is connected to the MOSFETdriver 905 which increases both the voltage and current to drive aMOSFET gate 906 which has a large capacitance and therefore requires adriver that can supply the necessary current.

The MOSFET 906 has its source connected to ground so that when it isturned on the drain will go close to ground and supply a voltagedifferential to the primary 918 of the step-up transformer as a resultof the other side of the primary winding being connected to the DC to DCpower supply 903.

The secondary 907 of the step-up transformer is connected to thenegative clamp circuit 908 that keeps the secondary voltage at apositive value. This is desirable because the MFCs can be driven to apositive 1500 volts if they are forward biased and only 500 volts ifthey are negatively biased. Because the load on the secondary of thetransformer 907 is primarily capacitive, like the MFCs, the secondary ofthe transformer in the capacitive load creates an electrical tankcircuit.

When the beam is exposed to tissue it may be pulled off of its resonantfrequency in free air and the program of the microprocessor 904 willadjust the frequency of the sinewave generator to maximize the voltagedisplacement detected by the sensor 913. If, however, a sudden drop ofvoltage is measured by the A/D 901 from the positive peak detector 916,the program running in the microcomputer will shut down the DC to DCpower supply and signal the surgeon that the beam may have contacted ahard substance such as bone. When the beam is in tissue, the output fromthe sensor is reduced from its voltage in free air.

The power to the beam MFCs is controlled by the microcomputer 904 usinga digital to analog converter 925 which provides output on line 900 tothe DC to DC power supply 903. The power can be adjusted by the surgeonusing up/down buttons 921 providing input to the microcomputer 904.

The beam MFCs can be operated in phase such that the distal end of thebeam moves in and out along the central axis of the beam or may beoperated out of phase such that the distal end of the beam is forced tomove perpendicular to the wide axis of the beam. The phase of the twosignals is controlled by the microcomputer 904 through an H-bridge 909.The H-bridge switches the leads of one of the MFCs so it either expandsat the same time as the opposite MFC to produce Fz motion or so theyexpand out of phase producing an My motion so that the MFCs cause awhipping action of the beam tip to occur. The H-bridge 909 is controlledby the Fz/My select signal, an I/O bit of the microcomputer 904.

The current of the sinewave generator is measured by the microcomputerA/D circuit using a current resistor 920 in the grounding circuit of theMOSFET 906. The current envelope signal from the peak detector 916 ismeasured by the A/D circuit of the microcomputer. This current willchange with various beam loading and can be used to optimize the tissuedestruction, or cut off power to the beam tip if the program instructsit to do so. The voltage displacement sensor 913 may be an MFC or otherpiezo device, strain gauge, an electromagnetic device, or any other typeof small displacement sensor. If the MFC is used, it produces a voltageusing the piezoelectric effect. A +peak detector 916 is used to convertthe AC voltage into a +voltage envelope that the A/D can easily convertto a digital value.

The microcomputer 904 controls a MOSFET driver 922 which controls a fan923 that cools the MFCs 910, 912 and also controls the waste heat from aPeltier junction 914 which cools the blocker 915 which supports theproximal end of the beam 911. The blocker 915 is made of a high modulusof elasticity material so that it reflects rather than absorbs the wavesemanating from the MFCs toward the proximal end of the beam 911 backtoward the distal end, rather than absorbing those waves. The distancefrom the end of the blocker to the MFC must be adjusted so that thereflected waves from the blocker are in phase with the MFC waves goingtoward the distal end of the beam, or energy will be lost.

A typical macro fiber composite (MFC) useful in the present invention isillustrated in FIG. 10 in exploded form before joining layers into asingle composite structure. The top layer 1001 is formed on arectangular layer of polyimide film and constitutes a pair of electrodestructures 1007 consisting of two side electrodes (shown in phantom asthey are formed on the underside of 1001), which are connected to thetwo output terminals of the H-bridge 909. Each of these side electrodeshas a group of electrode fingers extending normally to the sideelectrodes toward the opposite electrodes. These finger electrodes donot contact one another but are intended to bear against the epoxystructure so as to apply their opposite polarity electrical current tothe piezo ceramic rods 1003.

The second layer 1002 is a structural epoxy and supports and bonds theother actuator components together.

Layer 1003 is a sheet of aligned rectangular piezo fibers embedded in afiber composite material. These constitute composite rods with piezofibers integrated in them. The fourth layer 1004 is another layer ofstructural epoxy like layer 1002. The fifth layer 1005 is anotherinterdigitated pattern of electrodes like the top layer 1001. When thelayers are joined by the epoxy sheets they form a thinsurface-conformable sheet in a sealed and durable ready to use package.The electrodes are attached to the film and contact the ribbon-shapedrods of layer 1003 to transfer the applied voltage directly to and fromthe ribbon-shaped rods. When the assembled unit is affixed to one of thebeam beams such as 10, the electrical actuation of the ceramic rods oflayer 1003 can cause expansion or contraction of the surface of the beamto which they are attached. It can also act as a generator, sensingmotion of the beam tip 18 for feedback purposes as has been noted.

A cold plasma generator may be used with any of the forms of elongatedbeams disclosed in the present invention. As shown in the upper drawingof FIG. 11, two or more beams may be joined at an angle and used toincrease the total power at the distal end of the probe. As shown in thepart of FIG. 11 which is shown in phantom view, a cold plasma generatoris disposed adjacent to one of elongated beam.

The bottom drawing of FIG. 11 is an exploded view of the part of the topdrawing, which is shown in phantom view. An elongated beam 1110 has atapered distal end 1112 which is inserted into the body cavity to betreated, with the beam being cantilevered about its proximal end 1114. Apair of MFC pads 1116 and 1118 is attached to the surface of the beam1110 adjacent the proximal end. An electrode 1122 connected to asuitable high frequency power supply (not shown) at the proximal end1114 of the beam 1110 extends along the length of the beam andterminates at a plasma electrode 1124 forming part of a dielectricbreakdown device. A tube 1126 extending the length of the beam carries agas such as oxygen, nitrogen, air or water vapor which is expelled atthe distal end of the tube against the plasma electrode 1124. Theelectric field established between the electrodes 1122 and 1124 breaksdown and ionizes the gas. A coincident flow of a noble gas such ashelium creates the so-called cold atmospheric plasma which impacts theexcision site. This gas sterilizes the site and may staunch, orcoagulate, any blood flow.

A suction tube 1120 may be extended along the beam to remove vaporizedor dissected tissue from the excision site adjacent the distal end ofthe beam.

Cold plasma may also be generated at the proximal end of the beam byattaching a plasma generator insert at the proximal end of the device.FIG. 13 illustrates the manner of insertion of a DBD plasma generator1300 into an endoscope 1302, from the proximal end, in accordance withthe present invention.

The endoscope may have multiple channels and may include an imagingcable and an irrigation tube which extend along the length of the beam.The imaging cable may include optical fibers for illumination of thesurgical site and for imaging the site from the proximal end. Theimaging cable terminates at a viewing window at the proximal end andallows a surgeon to visualize the surgical site. The irrigation tubeterminates at a nozzle at the distal end and allows irrigation fluid ortherapeutic agent to be delivered through the nozzle to impinge upon thebacterial biofilms or to irrigate the treated area.

One problem in the plasma treatment of target area is that thedimensions of the plasma are small compared to the relative large areato be treated and the surface of the area to be treated is irregular. Anembodiment of the invention illustrated in FIG. 12 addresses theseproblems by generating plasma within a balloon structure which conformsto irregular surfaces and spreads the plasma over a relatively largearea. The inner balloon 1210 has a metalized coating on the inside andpreferably is formed of Mylar. The metal coating is connected to theplasma electrode 1222 and filled with pressurized gas through a gassupply tube (not shown). The inner balloon 1210 with its electrodesurface sits within an outer nonconductive balloon 1212. The volumebetween the inner balloon and the outer balloon is filled withpressurized gas through tiny apertures on the surface of the innerballoon. The outer balloon also has multiple tiny holes 1214 over itssurface and may take the form of mesh. Short fibrous webs 1216, orplastic foam, or bubbles of a liquid connect the inner surface of theouter balloon 1212 and the outer surface of the inner balloon 1210 tomaintain a uniform spacing between the two. A second plasma electrode(not shown) may be provided in the vicinity of the balloon. The electricfield established between two plasma electrodes will ionize the gas inthe space between the inner and outer balloons, the resulting plasmawill fill the volume between the two balloons and extend through themesh as multiple plumes which will treat the large targeted area.

Having thus described our invention, we claim:
 1. A system employing anelongated cantilevered beam having proximal and distal ends, with thedistal end adapted to be inserted into a body passage so that it engagestarget tissues to produce therapeutic effects on the tissues,comprising: piezoelectric material fixed to a surface of the beambetween the proximal and distal ends; an electrical excitation systemconnected to the piezoelectric material, wherein the electricalexcitation system is adapted to apply reciprocating currents to thepiezoelectric material layer to produce deformation of the beam; anelectrical power source; a source of gases; a cold plasma generatorconnected to the electrical power source and the source of gases, thecold plasma generator operable to ignite the gases to create cold plasmaand provide the plasma at the distal end of the beam.
 2. The system ofclaim 1, wherein the plasma is created adjacent to the distal end of thebeam by a dielectric breakdown device.
 3. The system of claim 1, whereinthe plasma is created adjacent to the proximal end of the beam and flowsby gas pressure to the distal end.
 4. The system of claim 1, wherein thecold plasma generator comprises a plasma electrode extending along thelength of the beam terminating at a second plasma electrode at thedistal end.
 5. The system of claim 1, further comprising a tubeextending along the length of the beam for providing irrigation fluidsor removing the target tissues adjacent the distal end of the beam. 6.The system of claim 1, further comprising an imaging channel terminatingat a viewing window.
 7. The system of claim 1, further comprising a pairof balloons supported at the distal end of the beam arranged with aninner balloon interior of an outer balloon and the volume between theinner and outer balloons is filled with pressurized gas, wherein theinner balloon is electrically connected to the plasma electrode.
 8. Thesystem of claim 1 wherein the piezoelectric material is fixed to twoopposed surfaces of the beam.
 9. The system of claim 1 wherein thepiezoelectric material comprises fibers that are formed as macro fibercomposites.
 10. The system of claim 1 wherein the deformation of thebeam is at the tip of the distal end.